Prototype Disclaimer

What program(s) is your household applying for today?

To apply for benefits, choose from the programs below. You can select more than one.

Household

Enter your name, date of birth, and anyone you live with. You can add up to four household members.

Your name Date of birth Household members

Household Members

Answer a few questions about each person.

Race (select all that apply)

Is this person married?

Please answer race and marital status.

Household Details

Next, you'll answer a few questions about your household.

Household Details

Please answer every question.

Household Details

Select who these situations apply to.

Please complete this question before continuing.

Household Income

Answer the following question about your household's Income.

Does your household make at least $580 in monthly income (includes all jobs, gig work, seasonal work, and unearned income such as unemployment)?

Income from seasonal work can be averaged across 6 months.

In which months did your household make at least $580 in income?

This helps us see if your household is already meeting Medicaid work requirements.

Please answer this question.

Income

Next, you'll answer a few questions about income.

Note on Income / Employment sections from Civilla: We do not recommend that states create new income or employment sections, only that they add questions about income last month, seasonal work, and a conditional question about last month's work hours for each job, to their existing income or employment sections as demonstrated in this prototype.

Income

Answer the following questions about Income for everyone applying for Medicaid.

Please answer every question.

Employment

List everyone who's working now or worked in the past 30 days.

Please complete all required fields for each job.

Self-Employment

List anyone in your household who is self-employed.

Please complete all required fields for each self-employment.

Additional Income

List anyone in your household who has additional income.

Please complete all required fields for each additional income.

Seasonal Work

Answer the following questions about seasonal work in your household.

Please select who is a seasonal worker and answer all follow-up questions.

Medicaid Work Requirements

Based on your application, the following people need to report 80 hours of work activities in .

Report work activities completed last month:

80 hours of work activities can be a combination of multiple activities. Check all that apply.

Review Your Application

Next, you will be asked to review your application.

Review Summary

Here's a summary of what was entered in this application.

Submitted!

Thanks for using this demo. We hope it helped show how our application recommendations and plain-language questions can be implemented.